Quality of life among 5,025 patients with left ventricular dysfunction randomized between placebo and enalapril: the Studies of Left Ventricular Dysfunction. The SOLVD Investigators

Quality of life in men and women with heart failure: association with outcome, and comparison between the Kansas City Cardiomyopathy Questionnaire and the EuroQol 5 dimensions questionnaire

Aims

We sought to analyse quality of life (QoL) measures derived from two questionnaires widely used in clinical trials, the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the EuroQoL 5 dimensions (EQ‐5D), and to compare their prognostic value in men and women with heart failure and reduced ejection fraction (HFrEF).

Methods and results

From the BIOlogy Study to TAilored Treatment in Chronic Heart Failure (BIOSTAT‐CHF) we compared KCCQ and EQ‐5D at baseline and after 9 months in 1276 men and 373 women with new‐onset or worsening symptoms of HFrEF, who were sub‐optimally treated and in whom there was an anticipated up‐titration of guideline‐derived medical therapies. Women had significantly worse baseline QoL (median) as compared with men, both when assessed with KCCQ overall score (KCCQ‐OS, 44 vs. 53, P < 0.001) and EQ‐5D utility score (0.62 vs. 0.73, P < 0.001). QoL improved equally in women and men at follow‐up. All summary measures of QoL were independently associated with all‐cause mortality, with KCCQ‐OS showing the most remarkable association with mortality up to 1 year compared to the EQ‐5D scores (C‐statistic 0.650 for KCCQ‐OS vs. 0.633 and 0.599 for EQ‐5D utility score and EQ‐5D visual analogue scale, respectively). QoL was associated with all outcomes analysed, both in men and women (all P for interaction with sex >0.2).

Conclusion

Amongst patients with HFrEF, women reported significantly worse QoL than men. QoL was independently associated with subsequent outcome, similarly in men and women. The KCCQ in general, and the KCCQ‐OS in particular, showed the strongest independent association with outcome.

Molecular, Cellular, and Clinical Evidence That Sodium-Glucose Cotransporter 2 Inhibitors Act as Neurohormonal Antagonists When Used for the Treatment of Chronic Heart Failure

Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of cardiovascular death and hospitalization for heart failure in patients with chronic heart failure. Initially, these drugs were believed to have a profile similar to diuretics or hemodynamically active drugs, but they do not rapidly reduce natriuretic peptides or cardiac filling pressures, and they exert little early benefit on symptoms, exercise tolerance, quality of life, or signs of congestion. Clinically, the profile of SGLT2 inhibitors resembles that of neurohormonal antagonists, whose benefits emerge gradually during sustained therapy. In experimental models, SGLT2 inhibitors produce a characteristic pattern of cellular effects, which includes amelioration of oxidative stress, mitigation of mitochondrial dysfunction, attenuation of proinflammatory pathways, and a reduction in myocardial fibrosis. These cellular effects are similar to those produced by angiotensin converting enzyme inhibitors, β-blockers, mineralocorticoid receptor antagonists, and neprilysin inhibitors. At a molecular level, SGLT2 inhibitors induce transcriptional reprogramming of cardiomyocytes that closely mimics that seen during nutrient deprivation. This shift in signaling activates the housekeeping pathway of autophagy, which clears the cytosol of dangerous cytosolic constituents that are responsible for cellular stress, thereby ameliorating the development of cardiomyopathy. Interestingly, similar changes in cellular signaling and autophagic flux have been seen with inhibitors of the renin-angiotensin system, β-blockers, mineralocorticoid receptor antagonists, and neprilysin inhibitors. The striking parallelism of these molecular, cellular, and clinical profiles supports the premise that SGLT2 inhibitors should be regarded as neurohormonal antagonists when prescribed for the treatment of heart failure with a reduced ejection fraction.

Disability and quality of life in heart failure patients: a cross-sectional study

BACKGROUND

Although both hospitalization and mortality due to heart failure (HF) have been widely studied, less is known about the impact of HF on disability and quality of life.

AIM

To assess the degree of disability and quality of life in HF patients attended at family medicine centres.

DESIGN AND SETTING

Cross-sectional study of a cohort of HF patients attended at family medicine centres.

METHODS

Disability was assessed with the WHODAS 2 questionnaire, which provides a global and six domain scores that is understanding and communication, getting around, self-care, getting along with people, life activities and participation in society. Quality of life was assessed with the Minnesota Living with Heart Failure Questionnaire, which furnishes a global and two domain scores, physical and emotional.

RESULTS

A breakdown of the results showed that 28% of patients had moderate disability and 16.7% had severe disability, with the most important areas affected being: life activities, 8.9% extreme disability and 30.3% severe disability; getting around, 34.6% severe disability and 2% extreme disability; and participation in society, 53.3% moderate-severe disability. Quality of life was mildly affected. New York Heart Association (NYHA) Functional Classification and sex were the major determinants of disability and quality of life. Angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists were associated with better scores in the "getting around" and "life activity" domains.

CONCLUSION

HF patients in primary care show an important degree of disability and an acceptable quality of life.

Detecting treatment differences in group sequential longitudinal studies with covariate adjustment

In longitudinal studies comparing two treatments over a series of common follow-up measurements, there may be interest in determining if there is a treatment difference at any follow-up period when there may be a non-monotone treatment effect over time. To evaluate this question, Jeffries and Geller (2015) examined a number of clinical trial designs that allowed adaptive choice of the follow-up time exhibiting the greatest evidence of treatment difference in a group sequential testing setting with Gaussian data. The methods are applicable when a few measurements were taken at prespecified follow-up periods. Here, we test the intersection null hypothesis of no difference at any follow-up time versus the alternative that there is a difference for at least one follow-up time. Results of Jeffries and Geller (2015) are extended by considering a broader range of modeled data and the inclusion of covariates using generalized estimating equations. Testing procedures are developed to determine a set of follow-up times that exhibit a treatment difference that accounts for multiplicity in follow-up times and interim analyses.

Medical interventions for treating anthracycline-induced symptomatic and asymptomatic cardiotoxicity during and after treatment for childhood cancer

BACKGROUND

Anthracyclines are frequently used chemotherapeutic agents for childhood cancer that can cause cardiotoxicity during and after treatment. Although several medical interventions in adults with symptomatic or asymptomatic cardiac dysfunction due to other causes are beneficial, it is not known if the same treatments are effective for childhood cancer patients and survivors with anthracycline-induced cardiotoxicity. This review is an update of a previously published Cochrane review.

OBJECTIVES

To compare the effect of medical interventions on anthracycline-induced cardiotoxicity in childhood cancer patients or survivors with the effect of placebo, other medical interventions, or no treatment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 8), MEDLINE/PubMed (1949 to September 2015), and EMBASE/Ovid (1980 to September 2015) for potentially relevant articles. In addition, we searched reference lists of relevant articles, conference proceedings of the International Society for Paediatric Oncology (SIOP), the American Society of Clinical Oncology (ASCO), the American Society of Hematology (ASH), the International Conference on Long-Term Complications of Treatment of Children & Adolescents for Cancer, and the European Symposium on Late Complications from Childhood Cancer (from 2005 to 2015), and ongoing trial databases (the ISRCTN Register, the National Institutes of Health (NIH) Register, and the trials register of the World Health Organization (WHO); all searched in September 2015).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or controlled clinical trials (CCTs) comparing the effectiveness of medical interventions to treat anthracycline-induced cardiotoxicity with either placebo, other medical interventions, or no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection. One review author performed the data extraction and 'Risk of bias' assessments, which another review author checked. We performed analyses according to the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

In the original version of the review we identified two RCTs; in this update we identified no additional studies. One trial (135 participants) compared enalapril with placebo in childhood cancer survivors with asymptomatic anthracycline-induced cardiac dysfunction. The other trial (68 participants) compared a two-week treatment of phosphocreatine with a control treatment (vitamin C, adenosine triphosphate, vitamin E, oral coenzyme Q10) in leukaemia patients with anthracycline-induced cardiotoxicity. Both studies had methodological limitations.The RCT on enalapril showed no statistically significant differences in overall survival, mortality due to heart failure, development of clinical heart failure, and quality of life between treatment and control groups. A post-hoc analysis showed a decrease (that is improvement) in one measure of cardiac function (left ventricular end-systolic wall stress (LVESWS): -8.62% change) compared with placebo (+1.66% change) in the first year of treatment (P = 0.036), but not afterwards. Participants treated with enalapril had a higher risk of dizziness or hypotension (risk ratio 7.17, 95% confidence interval 1.71 to 30.17) and fatigue (Fisher's exact test, P = 0.013).The RCT on phosphocreatine found no differences in overall survival, mortality due to heart failure, echocardiographic cardiac function, and adverse events between treatment and control groups.

AUTHORS' CONCLUSIONS

Only one trial evaluated the effect of enalapril in childhood cancer survivors with asymptomatic cardiac dysfunction. Although there is some evidence that enalapril temporarily improves one parameter of cardiac function (LVESWS), it is unclear whether it improves clinical outcomes. Enalapril was associated with a higher risk of dizziness or hypotension and fatigue. Clinicians should weigh the possible benefits with the known side effects of enalapril in childhood cancer survivors with asymptomatic anthracycline-induced cardiotoxicity.Only one trial evaluated the effect of phosphocreatine in childhood cancer patients with anthracycline-induced cardiotoxicity. Limited data with a high risk of bias showed no significant difference between phosphocreatine and control treatments on echocardiographic function and clinical outcomes.We did not identify any RCTs or CCTs studying other medical interventions for symptomatic or asymptomatic cardiotoxicity in childhood cancer patients or survivors.High-quality studies should be performed.

Assessing quality-of-life outcomes in cardiovascular clinical research

The field of quality-of-life (QOL) measurement grew out of attempts in the 1960s and 1970s to connect the ever-increasing levels of public expenditure on technology-based health care for chronic diseases with evidence of the benefits and harms to patients. Most of the concepts, methods, and standards for measuring QOL were derived from psychometrics, but the degree to which current tools adhere to these methods varies greatly. Despite the importance of QOL, patient-reported outcomes are not measured in most cardiovascular clinical trials. Lack of familiarity with QOL measures and their interpretation, and unrealistic expectations about the information these measures can provide, are obstacles to their use. Large clinical trials of revascularization therapy for coronary artery disease and medical treatments for heart failure show small-to-moderate QOL effects, primarily detected with disease-specific instruments. Larger treatment effects, seen in trials of device therapy for heart failure and ablation therapy for atrial fibrillation, have been detected with both generic and disease-specific instruments. A large gap remains between the parameters currently being measured in clinical research and the data needed to incorporate the 'patient's voice' into therapeutic decision-making.

Drug therapy for heart failure in older patients-what do they want?

Chronic heart failure (CHF) is predominantly seen in older patients, and therefore real life medicine often requires the extrapolation of findings from trials conducted in much younger populations. Prescribing patterns and potential benefits in the elderly are heavily influenced by polypharmacy and co-morbid pathologies. Increasing longevity may become less relevant in the frail elderly, whereas improving quality of life (QoL) often becomes priority; the onus being on improving wellbeing, maintaining independence for longer, and delaying institutionalisation. Specific studies evaluating elderly patients with CHF are lacking and little is known regarding the tolerability and side-effect profile of evidence based drug therapies in this population. There has been recent interest on the impact of heart rate in patients with symptomatic CHF. Ivabradine, with selective heart rate lowering capabilities, is of benefit in patients with CHF and left ventricular systolic dysfunction in sinus rhythm, resulting in reduction of heart failure hospitalisation and cardiovascular death. This manuscript will focus on CHF and the older patient and will discuss the impact of heart rate, drug therapies and tolerability. It will also highlight the unmet need for specific studies that focus on patient-centred study end points rather than mortality targets that characterise most therapeutic trials. An on-going study evaluating the impact of ivabradine on QoL that presents a unique opportunity to evaluate the tolerability and impact of an established therapy on a wide range of real life, older patients with CHF will be discussed.

Longitudinal clinical trials with adaptive choice of follow-up time

In longitudinal studies comparing two treatments with a maximum follow-up time there may be interest in examining treatment effects for intermediate follow-up times. One motivation may be to identify the time period with greatest treatment difference when there is a non-monotone treatment effect over time; another motivation may be to make the trial more efficient in terms of time to reach a decision on whether a new treatment is efficacious or not. Here, we test the composite null hypothesis of no difference at any follow-up time versus the alternative that there is a difference at at least one follow-up time. The methods are applicable when a few measurements are taken over time, such as in early longitudinal trials or in ancillary studies. Suppose the test statistic Z(t(k)) will be used to test the hypothesis of no treatment effect at a fixed follow-up time t(k). In this context a common approach is to perform a pilot study on N1 subjects, and evaluate the treatment effect at the fixed time points t1,…,t(K) and choose t* as the value of t(k) for which Z(t(k)) is maximized. Having chosen t* a second trial can be designed. In a setting with group sequential testing we consider several adaptive alternatives to this approach that treat the pilot and second trial as a seamless, combined entity and evaluate Type I error and power characteristics. The adaptive designs we consider typically have improved power over the common, separate trial approach.

Angiotensin receptor neprilysin inhibition compared with enalapril on the risk of clinical progression in surviving patients with heart failure

BACKGROUND

Clinical trials in heart failure have focused on the improvement in symptoms or decreases in the risk of death and other cardiovascular events. Little is known about the effect of drugs on the risk of clinical deterioration in surviving patients.

METHODS AND RESULTS

We compared the angiotensin-neprilysin inhibitor LCZ696 (400 mg daily) with the angiotensin-converting enzyme inhibitor enalapril (20 mg daily) in 8399 patients with heart failure and reduced ejection fraction in a double-blind trial. The analyses focused on prespecified measures of nonfatal clinical deterioration. In comparison with the enalapril group, fewer LCZ696-treated patients required intensification of medical treatment for heart failure (520 versus 604; hazard ratio, 0.84; 95% confidence interval, 0.74-0.94; P=0.003) or an emergency department visit for worsening heart failure (hazard ratio, 0.66; 95% confidence interval, 0.52-0.85; P=0.001). The patients in the LCZ696 group had 23% fewer hospitalizations for worsening heart failure (851 versus 1079; P<0.001) and were less likely to require intensive care (768 versus 879; 18% rate reduction, P=0.005), to receive intravenous positive inotropic agents (31% risk reduction, P<0.001), and to have implantation of a heart failure device or cardiac transplantation (22% risk reduction, P=0.07). The reduction in heart failure hospitalization with LCZ696 was evident within the first 30 days after randomization. Worsening of symptom scores in surviving patients was consistently more common in the enalapril group. LCZ696 led to an early and sustained reduction in biomarkers of myocardial wall stress and injury (N-terminal pro-B-type natriuretic peptide and troponin) versus enalapril.

CONCLUSIONS

Angiotensin-neprilysin inhibition prevents the clinical progression of surviving patients with heart failure more effectively than angiotensin-converting enzyme inhibition.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT01035255.

Health-related quality of life in elderly patients hospitalized with chronic heart failure

Background

Chronic heart failure is a very common condition in the elderly, characterized not only by high mortality rates, but also by a strong impact on health-related quality of life (HRQOL). Previous studies of HRQOL in elderly heart failure subjects have included mostly outpatients, and little is known about determinants of HRQOL in hospitalized elderly population, especially in Serbia. In this study, we tried to identify factors that influence HRQOL in elderly patients hospitalized with chronic heart failure in Serbia.

Methods

The study population consisted of 136 patients aged 65 years or older hospitalized for chronic heart failure. HRQOL was assessed using the Minnesota Living with Heart Failure questionnaire. Predictors of HRQOL were identified by multiple linear regression analysis.

Results

Univariate analysis showed that patients with lower income, a longer history of chronic heart failure, and longer length of hospital stay, as well as those receiving aldosterone antagonists and digoxin, taking multiple medications, in a higher NYHA class, and showing signs of depression and cognitive impairment had significantly worse HRQOL. Presence of depressive symptoms (P<0.001), higher NYHA class (P=0.021), lower income (P=0.029), and longer duration of heart failure (P=0.049) were independent predictors of poor HRQOL.

Conclusion

Depressive symptoms, higher NYHA class, lower income, and longer duration of chronic heart failure are independent predictors of poor HRQOL in elderly patients hospitalized with chronic heart failure in Serbia. Further, there is an association between multiple medication usage and poor HRQOL, as well as a negative impact of cognitive impairment on HRQOL. Hence, measures should be implemented to identify such patients, especially those with depressive symptoms, and appropriate interventions undertaken in order to improve their HRQOL.

Identifying differential responders and their characteristics in clinical trials: innovative methods for analyzing longitudinal data

OBJECTIVES

To present a step-by-step example of the examination of heterogeneity within clinical trial data by using a growth mixture modeling (GMM) approach.

METHODS

Secondary data from a longitudinal double-blind clinical drug study were used. Patients received enalapril or placebo and were followed for 2 years during the drug component, followed by a 3-year postdrug component. Primary variables of interest were creatinine levels during the drug component and number of hospitalizations in the postdrug component. Latent growth modeling (LGM) methods were used to examine the treatment response variability in the data. GMM methods were applied where substantial variability was found to identify latent (unobserved) subsets of differential responders, using treatment groups as known classes. Post hoc analyses were applied to characterize emergent subgroups.

RESULTS

LGM methods demonstrated a large variability in creatinine levels. GMM methods identified two subsets of patients for each treatment group. Placebo class 2 (7.0% of the total sample) and enalapril class 2 (8.5%) include individuals whose creatinine levels start at 1.114 mg/dl and 1.108 mg/dl, respectively, and show worsening (slopes: 0.023 and 0.017, respectively). Placebo class 1 (43.1%) and enalapril class 1 (41.4%) individuals start with lower creatinine levels (1.082 and 1.083 mg/dl, respectively) and show very minimal change (0.008 and 0.003, respectively). Post hoc analyses revealed significant differences between placebo/enalapril class 1 and placebo/enalapril class 2 in terms of New York Heart Association functional ability, depression, functional impairment, creatinine levels, mortality, and hospitalizations.

CONCLUSIONS

GMM methods can identify subsets of differential responders in clinical trial data. This can result in a more accurate understanding of treatment effects.

Quality of life and chronic heart failure therapy guided by natriuretic peptides: results from the ProBNP Outpatient Tailored Chronic Heart Failure Therapy (PROTECT) study

BACKGROUND

Heart failure (HF) treatment guided by amino-terminal pro-B type natriuretic peptide (NT-proBNP) may reduce cardiovascular event rates compared to standard-of-care (SOC) management. Comprehensive understanding regarding effect of NT-proBNP guided care on patient-reported quality of life (QOL) remains unknown.

METHODS

One hundred fifty-one subjects with HF due to left ventricular systolic dysfunction were randomized to either SOC HF management or care with a goal to reduce NT-proBNP values ≤1000 pg/mL. Effects of HF on QOL were assessed using the Minnesota Living with HF Questionnaire (MLHFQ) quarterly, with change (Δ) in score assessed across study procedures and as a function of outcome.

RESULTS

Overall, baseline MLHFQ score was 30. Across study visits, QOL improved in both arms, but was more improved and sustained in the NT-proBNP arm (repeated measures P = .01); NT-proBNP patients showing greater reduction in MLHFQ score (-10.0 vs -5.0; P = .05), particularly in the physical scale of the questionnaire. Baseline MLHFQ scores did not correlate with NT-proBNP; in contrast, ∆MLHFQ scores modestly correlated with ∆NT-proBNP values (ρ = .234; P = .006) as did relative ∆ in MLHFQ score and NT-proBNP (ρ = .253; P = .003). Considered in tertiles, less improvement in MLHFQ scores was associated with a higher rate of HF hospitalization, worsening HF, and cardiovascular death (P = .001).

CONCLUSIONS

We describe novel associations between NT-proBNP concentrations and QOL scores among patients treated with biomarker guided care. Compared to SOC HF management, NT-proBNP guided care was associated with greater and more sustained improvement in QOL (Clinical Trial Registration: www.clinicaltrials.govNCT00351390).

Subclinical myocardial dysfunction in patients with reverse-remodeled dilated cardiomyopathy

BACKGROUND

The aim of this study was to test the hypothesis that patients with reverse-remodeled dilated cardiomyopathy (DCM), whose ejection fractions (EFs) were normalized after optimal pharmacologic therapy, had subclinical myocardial dysfunction.

METHODS

Thirty-two patients with reverse-remodeled DCM, defined as having an initial EF ≤ 35%, which then recovered to ≥50% after optimal pharmacologic therapy, and 11 normal controls with preserved EFs were retrospectively studied. Averaged peak systolic and early diastolic radial, circumferential, and longitudinal speckle-tracking strain rates were assessed from an 18-segment left ventricular model. Similarly, averaged peak systolic radial, circumferential, and longitudinal speckle-tracking strain was obtained.

RESULTS

Peak systolic and early diastolic longitudinal strain rates, peak systolic and early diastolic circumferential strain rates, and peak circumferential and longitudinal strain in patients with reverse-remodeled DCM were significantly lower than those in normal controls, but peak systolic and early diastolic radial strain rates and peak radial strain in patients with reverse-remodeled DCM were similar to those in normal controls. Isometric handgrip stress testing showed a significant decrease in EF from 56 ± 5% to 51 ± 5% (P < .001). Of note, the increase of afterload resulting from isometric handgrip stress testing was associated with a decrease in peak systolic circumferential and longitudinal strain rates and peak circumferential strain in patients with reverse-remodeled DCM.

CONCLUSIONS

The circumferential and longitudinal myocardial function of patients with reverse-remodeled DCM is lower compared with that of normal controls with preserved EFs. Furthermore, the increase in afterload was associated with the decrease in circumferential and longitudinal myocardial systolic function. These findings suggest that in treated patients with DCM with reverse remodeling, left ventricular mechanics may not be normal, even when EFs are normal.

What is the methodological and reporting quality of health related quality of life in chronic heart failure clinical trials?

BACKGROUND

Although the number of clinical trials assessing health related quality of life (HRQoL) in chronic heart failure (CHF) has increased exponentially over the last decade, little is known about the quality of reporting. The purpose of this review was to assess the methodological and reporting rigor of HRQoL in RCTs of pharmacological therapy in CHF.

METHODS

The electronic data bases, Medline and EMBASE were searched from 1990 to 2009 using the key search terms 'heart failure' combined with 'quality of life', 'pharmacological therapy' and 'randomized controlled trials'. A total of 136 articles were identified and evaluated according to the "Minimum Standard Checklist (MSC) for Evaluating HRQoL Outcomes".

RESULTS

According to the MSC criteria, 26 (19.1%) studies were considered 'very limited', 91 (66.9%) were 'limited' and only 19 (14.0%) studies were considered to be of a 'probably robust' in terms of methodological and reporting rigor. In fact, the quality of HRQoL reporting has not improved over time.

CONCLUSION

HRQoL is a critical consideration in CHF management, yet reporting is highly variable. There is a need to develop a standardized method for measuring and reporting HRQoL measures in clinical trials to aid in the interpretation and application of findings.

Medical interventions for treating anthracycline-induced symptomatic and asymptomatic cardiotoxicity during and after treatment for childhood cancer

BACKGROUND

Anthracyclines are frequently used chemotherapeutic agents for childhood cancer that can cause cardiotoxicity during and after treatment. Although several medical interventions in adults with symptomatic or asymptomatic cardiac dysfunction due to other causes are beneficial, it is not known if the same treatments are effective for childhood cancer patients and survivors with anthracycline-induced cardiotoxicity.

OBJECTIVES

To compare the effect of medical interventions on anthracycline-induced cardiotoxicity in childhood cancer patients or survivors with the effect of placebo, other medical interventions or no treatment.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2011, issue 1), MEDLINE/PubMed (1949 to May 2011) and EMBASE/Ovid (1980 to May 2011) for potentially relevant articles. We additionally searched reference lists of relevant articles, conference proceedings and ongoing trial databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or controlled clinical trials (CCTs) comparing the effectiveness of medical interventions to treat anthracycline-induced cardiotoxicity with either placebo, other medical interventions or no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection. One review author performed the data extraction and 'Risk of bias' assessments which were checked by another review author.

MAIN RESULTS

We identified two RCTs. One trial (135 patients) compared enalapril with placebo in childhood cancer survivors with asymptomatic anthracycline induced cardiac dysfunction. The other trial (68 patients) compared a two-week treatment of phosphocreatine with a control treatment (vitamin C, ATP, vitamin E, oral coenzyme Q10) in leukaemia patients with anthracycline-induced cardiotoxicity. Both studies had methodological limitations.The RCT on enalapril showed no (statistically) significant differences in overall survival, mortality due to heart failure, development of clinical heart failure and quality of life between treatment and control group. A post-hoc analysis showed a decrease (i.e. improvement) in one measure of cardiac function (left ventricular end systolic wall stress (LVESWS): -8.62% change) compared with placebo (+1.66% change) in the first year of treatment (P = 0.036), but not afterwards. Patients treated with enalapril had a higher risk of dizziness or hypotension (RR 7.17, 95% CI 1.71 to 30.17) and fatigue (Fisher's exact test, P = 0.013).The RCT on phosphocreatine found no differences in overall survival, mortality due to heart failure, echocardiographic cardiac function and adverse events between treatment and control group.

AUTHORS' CONCLUSIONS

For the effect of enalapril in childhood cancer survivors with asymptomatic cardiac dysfunction, only one RCT is available. Although there is some evidence that enalapril temporarily improves one parameter of cardiac function (LVESWS), it is unclear whether it improves clinical outcomes. Enalapril was associated with a higher risk of dizziness or hypotension and fatigue. Clinicians should weigh the possible benefits with the known side-effects of enalapril in childhood cancer survivors with asymptomatic anthracycline-induced cardiotoxicity.For the effect of phosphocreatine in childhood cancer patients with anthracycline-induced cardiotoxicity, only one RCT is available. Limited data with a high risk of bias showed no significant difference between phosphocreatine and control treatment on echocardiographic function and clinical outcomes.We did not identify any RCTs or CCTs studying other medical interventions for symptomatic or asymptomatic cardiotoxicity in childhood cancer patients or survivors.High-quality studies should be performed.

Dilated cardiomyopathy

Dilated cardiomyopathy is characterised by left ventricular dilation that is associated with systolic dysfunction. Diastolic dysfunction and impaired right ventricular function can develop. Affected individuals are at risk of left or right ventricular failure, or both. Heart failure symptoms can be exercise-induced or persistent at rest. Many patients are asymptomatic. Chronically treated patients sometimes present acutely with decompensated heart failure. Other life-threatening risks are ventricular arrhythmias and atrioventricular block, syncope, and sudden death. Genetic inheritance arises in 30-48% of patients, and inflammatory disorders such as myocarditis or toxic effects from medications, alcohol, or illicit drugs also result in dilated cardiomyopathy. Genes that cause dilated cardiomyopathy generally encode cytoskeletal and sarcomeric (contractile apparatus) proteins, although disturbance of calcium homeostasis also seems to be important. In children, disrupted mitochondrial function and metabolic abnormalities have a causal role. Treatments focus on improvement of cardiac efficiency and reduction of mechanical stress. Arrhythmia therapy and prevention of sudden death continue to be mainstays of treatment. Despite progress over the past 10 years, outcomes need to be improved.

Heart failure guidelines and implications for surgically treating heart failure

In 2005, the American College of Cardiology and the American Heart Association released updated guidelines for the diagnosis and management of chronic heart failure in the adult, yielding new insights into the progression and treatment of this disease. Perioperative nurses need a working knowledge of these guidelines to provide optimal care when patients require surgical interventions for heart failure. This article provides an overview of the pathophysiology, classifications, and treatments for heart failure.

Effects of cardiac resynchronization therapy on long-term quality of life: an analysis from the CArdiac Resynchronisation-Heart Failure (CARE-HF) study

BACKGROUND

Cardiac resynchronization therapy (CRT) improves quality of life (QoL) when measured 3 to 6 months after implantation, but whether these effects are sustained is unknown. The CArdiac Resynchronisation-Heart Failure study is the only long-term randomized trial of CRT with repeated measures of QoL.

METHODS

Quality of life was measured at baseline and 3 months using generic European Quality of Life-5 Dimensions and disease-specific (Minnesota Living with Heart Failure) questionnaires and at 18 months and study-end using the latter instrument. Median follow-up was 29.6 (interquartile range 23.6-34.6) months.

RESULTS

At baseline, patients had a substantially impaired QoL (mean European Quality of Life-5 Dimensions score 0.60, 95% confidence interval [CI] 0.58-0.62) compared to an age-matched general population (0.78, 95% CI 0.76-0.80). Quality of life improved to a greater extent in patients assigned to CRT at each time point (P < .0001). By 18 months, the mean difference in disease-specific QoL score was 10.7 (95% CI 7.6-13.8) in favor of CRT, mostly due to improved physical functioning. Differences were sustained thereafter. Quality-adjusted life-years at 18 months increased by 0.13 (95% CI 0.07-0.182) and by 0.23 (95% CI 0.13-0.33) at study-end (both P < .0001). Little heterogeneity of effect across subgroups was observed.

CONCLUSION

Cardiac resynchronization therapy improves long-term QoL and survival in patients with moderate to severe heart failure. The effects appear sustained, and therefore, the gain in quality-adjusted life years with CRT should be even greater during longer term follow-up.

New and emerging pharmacologic strategies in the management of chronic heart failure

Chronic heart failure (CHF) is a complex syndrome involving activation of multiple cellular, metabolic, and neurohumoral pathways following the initial myocardial insult. Recently, there have been considerable advances in the pharmacologic management of CHF. The current approach to treatment recognizes the need to target neurohormonal activation, and the use of angiotensin-converting enzyme (ACE) inhibitors and beta blockers should now be regarded as part of standard therapy in many patients with CHF. However, because of the complexity of the disease, blockade of additional pathways is likely to be required to maximize the therapeutic benefit of intervention. To this end, there are several agents under active late-phase clinical evaluation. The most advanced of these new strategies (beyond renin-angiotensin-aldosterone blockade) is inhibition of the endothelin system. There is a substantial body of evidence that this system is intimately involved in CHF disease progression. Early-phase clinical data are very encouraging and support the potential utility of long-term endothelin inhibition. Other novel approaches involve the use of cytokine antagonists (e.g., agents that block tumor necrosis factor-alpha activity) and the augmentation of natriuretic peptides. If all these potential agents prove to be of benefit in CHF, the question of which agent or combination of agents to use in which patients will arise. There is therefore a need to develop scientific approaches in order to be able to identify more accurately patients who will obtain benefit from specific classes or combinations of drugs.

Symptomatic improvement and reduced hospitalization for patients attending a cardiomyopathy clinic

BACKGROUND

The major costs associated with the management of congestive heart failure (CHF) are inpatient costs. Outcome studies are therefore important to establish whether intensive outpatient care for heart failure can reduce these costs while at the same time improving outcomes in this disabling disorder.

HYPOTHESIS

Care delivered in a cardiomyopathy clinic might result in objective improvement in cardiac function and symptoms while reducing hospital admissions and emergency department visits.

METHODS

The outcomes of 21 patients treated for 6 months in a cardiomyopathy clinic are evaluated. New patients referred to the clinic with ejection fraction (EF) < 0.45 were enrolled. The Minnesota Living with Heart Failure questionnaire was completed at initial and final visits. All patients underwent baseline and final echocardiogram, radionuclide left ventriculogram, and cardiopulmonary exercise testing. Patients were followed by a nurse practitioner and a cardiologist with maximization of standard treatment. Congestive heart failure-related hospitalizations and clinic and emergency room visits for both 6-month periods before and during the study were determined.

RESULTS

There was significant (p < 0.05) improvement in these parameters: Heart failure score increased 23 points; New York Heart Association class decreased from 2.6 to 2.2; EF increased from 0.24 to 0.36; diastolic and systolic left ventricular dimensions decreased from 65 to 59 mm and from 57 to 50 mm, respectively. The number of clinic visits increased 5-fold, whereas there were 86% (14 to 2, p = 0.017) and 100% (8 to 0, p = 0.002) reductions in the number of CHF hospitalizations and emergency visits. There was one death during follow-up.

CONCLUSION

Managing patients in a cardiomyopathy clinic may result in a better quality of life, with both symptomatic improvement and decreased hospitalizations.

Integrating co-morbid depression and chronic physical disease management: identifying and resolving failures in self-regulation

Research suggests that treatments for depression among individuals with chronic physical disease do not improve disease outcomes significantly, and chronic disease management programs do not necessarily improve mood. For individuals experiencing co-morbid depression and chronic physical disease, demands on the self-regulation system are compounded, leading to a rapid depletion of self-regulatory resources. Because disease and depression management are not integrated, patients lack the understanding needed to prioritize self-regulatory goals in a way that makes disease and depression management synergistic. A framework in which the management of co-morbidity is considered alongside the management of either condition alone offers benefits to researchers and practitioners and may help improve clinical outcomes.

Health-related quality of life in unselected outpatients with heart failure across Spain in two different health care levels. Magnitude and determinants of impairment: the INCA study

AIMS

To assess health-related quality of life (HRQL) in Spanish outpatients with chronic heart failure (CHF).

METHODS

Cross-sectional study carried out in a sample of CHF patients (echocardiography was performed in all of them) followed either in Primary Care (PC) centres or Cardiology outpatient clinics throughout Spain. HRQL was evaluated using the EuroQol 5D (EQ-5D) and Minnesota Living with Heart Failure (MLWHF) Questionnaire.

RESULTS

The study subjects were 2161 CHF patients (1412 PC; 749 Cardiology). Patients were older and had more severe disease in PC than in Cardiology settings. Their HRQL scores were likewise worse. After adjusting for clinical variables, the differences in global and physical MLWHF disappeared, but persisted to a smaller degree in EQ-5D and mental MLWHF. HRQL was worse than in a representative sample of the Spanish population and in other chronic conditions such as rheumatoid arthritis or type 2 diabetes, being only comparable to severe chronic obstructive pulmonary disease (COPD).

CONCLUSION

All domains of HRQL were significantly impaired in CHF patients. Differences found in HRQL between PC and Cardiology should possibly be attributed to a large extent to the different clinical characteristics of the patients attended. In spite of the differences between EQ-5D and MLWHF, our results suggest that both questionnaires adequately reflect the severity of the disease.

Multidisciplinary management of elderly patients with chronic heart failure: five year outcome measures in death and survivor groups

BACKGROUND

The utility of multidisciplinary chronic disease evaluation measures, especially health related quality of life (HRQL), for long long-term prognostic use in elderly patients with heart failure is uncertain.

AIM

To report on clinical, functional and HRQL values of deceased and surviving patients of a 6-month RCT of Cardiac Rehabilitation in addition to specialist nurse outpatient clinic at 5 years.

METHODS

The original measures (walk test, Borg RPE, MLHF, EuroQol score and vas, biochemistry) were repeated for patients in a satisfactory condition.

RESULTS

Five year survival was characterised by significantly better baseline values for LV dysfunction and NYHA class and 6-month values for MLHF, physical function and biochemistry measures. EuroQuol scores were worse than baseline for surviving patients at 5 years, in contrast to MLHF scores. The walk test gave the highest 5-year relative mortality risk, whereas the MLHF gave similar values to the Borg and uric acid measures. Deaths were more evident in normal weight older patients than in younger obese patients.

CONCLUSION

Changes in patient measures were evident over 5 years and most differentiated between survivor and deceased groups. In comparison to the use of the MLHF and EuroQuol-vas, the EuroQuol score was limited by impairments of the ageing process.

The enigma of quality of life in patients with heart failure

Current treatment goals in heart failure (HF) aim to improve both survival and quality of life (QoL) of patients. In this brief communication, we reviewed randomized controlled trials that assessed the impact of pharmacological treatment on QoL, and we discussed some methodological limitations of QoL assessment in HF. Studies that assessed QoL with a disease-specific questionnaire were included. We found that at present there is a paradox in HF treatment. Life prolonging therapies, such as angiotensin-converting-enzyme-inhibitors, and angiotensin receptor blockers improve modestly or only delay the progressive worsening of QoL in HF. Treatment with beta blockers does not affect QoL in any way. However, this neutral effect of beta blockers may also be due to some methodological limitations, such as the small number of patients included in beta blocker trials or the short duration of follow-up. Disease-specific questionnaires may also have some limitations, e.g. are not sensitive enough to detect small changes in QoL. On the other hand, therapies that significantly improve QoL in HF (e.g. inotropic agents) do not seem beneficial in relation to survival. We conclude that QoL in HF remains an open field, in which new therapies but also clarification of methodology is required. In the mean time, the use of life prolonging therapies appears as a safe measure to modestly improve or maintain QoL.

Recovery of normal ventricular function in patients with dilated cardiomyopathy: predictors of an increasingly prevalent clinical event

BACKGROUND

This investigation was designed to identify clinical variables associated with recovery of normal ventricular function in patients with dilated cardiomyopathy treated with medical therapy. Recovery of normal ventricular function with medical treatment of patients with dilated cardiomyopathy is observed with increasing frequency. However, the clinical variables associated with such dramatic improvement of ventricular performance are poorly defined.

METHODS

Fifty-three patients with dilated cardiomyopathy and reduced ejection fractions who achieved an increase in ejection fraction to > or = 40% with medical therapy were identified during follow-up in a dedicated heart failure clinic. A cohort of patients frequency-matched on baseline ejection fraction who did not recover ventricular systolic function to this magnitude constituted the control group. Clinical variables characterizing the 2 groups were compared by univariable analysis. Variables that significantly differed between the 2 groups were entered in a stepwise logistic regression analysis to identify factors independently associated with recovery of ejection fraction to > or = 40%.

RESULTS

In the final logistic regression model, QRS duration, sex, etiology of cardiomyopathy, diabetes, and systolic blood pressure were significantly associated with improvement of ejection fraction to > or = 40%.

CONCLUSIONS

Five clinical variables that are independently associated with improvement of left ventricular ejection fraction to normal or near-normal values with medical therapy alone were identified by this modeling process. These variables may be used to discriminate between patients in whom ventricular function will normalize with medical therapy alone and those who will require more aggressive pharmacologic or device therapy.

Analyzing growth and change: latent variable growth curve modeling with an application to clinical trials

OBJECTIVE

Typical methods of analyzing data from clinical trials have shortcomings, notably comparisons of group means, use of change scores from pre- and post-treatment assessments, ignoring intervening assessments, and focusing on direct effects of treatment. A comparison of group means disregards the likelihood that individuals have different trajectories of change. Moreover, change scores ignore intervening assessments that may provide useful information about change. This paper compares results from traditional regression-based methods for analyzing data from a clinical trial (e.g., regression with change scores) with those of latent growth curve modeling (LGM).

METHODS

LGM is a method that uses structural equation modeling techniques to model individual change, assess treatment effects and the relationship among multiple outcomes simultaneously, and model measurement error. The consequence is more precise parameter estimates while using data from all available time points.

RESULTS

Results demonstrate that LGM can yield stronger parameter estimates than the traditional regression-based approach and explain more variance in the outcome. In trials where there is a true effect, but it is non-significant or marginally significant using the traditional methods, LGM may provide evidence of this effect.

CONCLUSIONS

Analysts are encouraged to consider LGM as an additional and informative tool for analyzing clinical trial or other longitudinal data.

[Hypertension and cardiac failure]

Arterial hypertension is the leading cause of mortality and morbidity with a worldwide prevalence of 26%. Aging increases the incidence of arterial hypertension. Arterial hypertension is the prime example for a chronic disease with asymptomatic beginning, creeping course and fatal outcome. Arterial hypertension is a major cardiovascular risk factor and leads to vascular as well as myocardial manifestations: coronary artery disease, hypertensive microvascular disease, concentric left ventricular hypertrophy as well as perivascular and interstitial fibrosis. In the late stages of the disease, hypertrophy and cardiac failure develop. Arterial hypertension is the leading cause of coronary artery disease and cardiac failure, and coronary artery disease is the cause of heart failure in 50% of cases. Various non-invasive and invasive procedures are available for screening and follow-up. The primary therapeutic target is to reverse cardiac manifestations of arterial hypertension using specific therapeutic algorithms as well as lowering blood pressure. This article covers the pathophysiology of arterial hypertension and cardiac failure, clinical symptoms, diagnostic options and therapeutical goals as well as medicinal options.

Effect of Drug Therapy for Heart Failure on Quality of Life

Symptomatic heart failure interferes with a patient's quality of life (QOL) by limiting his or her ability to perform physical tasks and daily activities and by lowering his or her sense of psychological well-being. Therefore, in addition to decreasing mortality and morbidity, improving QOL should be an important goal when selecting pharmacotherapy. QOL questionnaires, both generic and disease specific, are used widely, but in randomized controlled trials of heart failure treatments, QOL has not been a routine study end point. Beta blockers and angiotensin-converting enzyme inhibitors, medications widely used in the management of heart failure and hypertension--one of the most common causes of heart failure--have been associated with negative, neutral, and modestly positive QOL effects. Angiotensin receptor blockers, combined with other therapy, including angiotensin-converting enzyme inhibitors (usually with a diuretic) and/or b blockers in heart failure, have produced improvements in QOL. Patients with hypertension whose blood pressure has been lowered have also experienced an improvement in QOL scores. With current heart failure regimens prolonging life, improving QOL becomes an even more essential end point in assessing the effectiveness of new medications, whether used alone or in combination with standard therapy.

Medication adherence in heart failure

Non-adherence with medical regimens in heart failure is a significant challenge and serves as a major reason that favorable outcomes associated with various therapies evaluated in clinical trials have not translated to the so-called real-world setting. Non-adherence has complex influences and is clearly associated with poorer outcomes. The approaches that are used or have been proposed to improve drug-taking behavior, such as in-hospital initiation of therapy, simplification of dosing regimens through adoption of combination and long-acting formulations, and improvements in provider-patient communication, are reviewed.

Dosage dependent hormonal counter regulation to combination therapy in patients with left ventricular dysfunction

The present study attempts to assess the efficacy combination therapy for heart failure. Genuine dose-response studies on combination therapy are not available and published studies involved adding one drug on top of 'usual treatment'. Sixteen different dosage combinations of trandolapril and bumetanide was tested in a double blind, double placebo-controlled, randomized, multiple cross-over study in a 16 times six balanced incomplete Latin square design. Patients reported optimal quality of life on the sub maximal dose bumetanide. Bumetanide decreased left ventricular function and increased heart rate and plasma noradrenaline in a dose dependent manner. Doses of bumetanide of more than 0.5 mg, given twice daily significantly decreased the quality of life and increased diuresis. Weight loss was maximal on 0.5 mg bumetanide twice daily. Trandolapril significantly reduced systolic blood pressure with the maximal effect at 0.5 mg daily. Both drugs significantly increased renin concentration with a significant potentiating interaction. It was not possible to detect beneficial effects of combination therapies. The optimal dosage of Bumetanide appeared to be 0.5 mg twice daily based on its effect on quality of life and weight loss. Estimated by the reduction in systolic blood pressure the optimal dosage of Trandolapril appeared to be 0.5 mg once daily.

CONCLUSIONS

It appears that patients should be given less than the usually recommended dosages. Patients may be treated with a low dose loop diuretic, if signs of water retention are present or if symptomatic relief is desired.

A Comparison of the Effects of Carvedilol and Metoprolol on Well-Being, Morbidity, and Mortality (the “Patient Journey”) in Patients With Heart Failure

OBJECTIVES

This study was designed to investigate the loss of well-being, in terms of life-years, overall and in patients randomized to metoprolol versus carvedilol in the Carvedilol Or Metoprolol European Trial (COMET).

BACKGROUND

The ultimate objectives of treating patients with heart failure are to relieve suffering and prolong life. Although the effect of treatment on mortality is usually described in trials, the effects on patient well-being throughout the trials' courses are rarely reported.

METHODS

A total of 3,029 patients randomized in the COMET study were included in the analysis. "Patient journey" was calculated by adjusting days alive and out of hospital over four years using a five-point score completed by the patient every four months, adjusted according to the need for intensification of diuretic therapy. Scores ranged from 0% (dead or hospitalized) to 100% (feeling very well).

RESULTS

Over 48 months, 17% of all days were lost through death, 1% through hospitalization, 23% through impaired well-being, and 2% through the need for intensified therapy. Compared with metoprolol, carvedilol was associated with fewer days lost to death, with no increase in days lost due to impaired well-being or days in hospital. The "patient journey" score improved from a mean of 54.8% (SD 26.0) to 57.4% (SD 26.3%) (p < 0.0068).

CONCLUSIONS

Despite treatment with beta-blockers, heart failure remains associated with a marked reduction in well-being and survival. Loss of quality-adjusted life-years through death and poor well-being seemed of similar magnitude over four years, and both were much larger than the loss that could be attributed to hospitalization.

Cardiac monitoring and treatment for children and adolescents with neuromuscular disorders

Dilated cardiomyopathy, hypertrophic cardiomyopathy, and cardiac rhythm disturbances are important features of certain neuromuscular disorders in children, adolescents, and young adults. This article summarizes the cardiac features seen in patients with Duchenne muscular dystrophy, Becker muscular dystrophy, myotonic dystrophy, Friedreich's ataxia, and Emery-Dreifuss muscular dystrophy. The optimal management of these cardiac features remains contentious, but increasingly these patients are referred for routine cardiological assessment in the absence of symptoms. This article examines the value of routine screening and drug interventions for cardiac complications in asymptomatic and symptomatic individuals with neuromuscular disorders. We recommend a pragmatic approach, actively looking for cardiac conditions which will benefit from early intervention, but avoiding routine screening for asymptomatic conditions in which there is no evidence of benefit from early intervention.

Effect of angiotensin-converting enzyme inhibition on functional class in patients with left ventricular systolic dysfunction-a meta-analysis

BACKGROUND

The effect of angiotensin converting enzyme (ACE) inhibitors on symptoms in patients with left ventricular systolic dysfunction (LVSD) is controversial.

AIMS

To perform a meta-analysis of studies evaluating effect of ACE inhibitors on New York Heart Association (NYHA) class in patients with LVSD.

METHODS

Individual data from 10389 patients in NYHA classes I-IV from four large long-term studies (2-4-year follow-up) and summary data from 2302 patients in NYHA classes II-IV from 16 short-term studies (3 months follow-up) were meta-analysed to assess changes in NYHA class.

RESULTS

The large long-term studies showed a significant improvement in the worst NYHA classes (classes II-IV compared to class I) in the ACE inhibitor arm versus placebo, odds ratio (OR) = 0.875 (0.811-0.943) p = 0.0005. This effect was only present in studies which included patients with chronic heart failure and was particularly pronounced on deterioration to the worst NYHA class IV, OR = 0.66 (0.52-0.84) p = 0.001. There was no effect in the studies which included patients after myocardial infarction. The short-term chronic heart failure studies showed a significant improvement in NYHA class; OR for improvement of at least one NYHA class was 2.11 (1.48-2.98, 95% CI) p < 0.0001.

CONCLUSION

ACE inhibition significantly improves symptomatic status measured as NYHA classification in patients with chronic heart failure.

Testing a published model of health-related quality of life in heart failure

BACKGROUND

Health-related quality of life (HRQOL) in patients with heart failure is compromised and associated with increased mortality and rehospitalization. Inadequate conceptualization of variables related to HRQOL has hampered clinicians' efforts to enhance HRQOL. The purpose of this study was to test the Wilson and Cleary model (WCM) of HRQOL in patients with heart failure.

METHODS AND RESULTS

Data from 293 patients with heart failure were analyzed to determine the best multivariate HRQOL model given variables derived from WCM. HRQOL was measured using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). Health perception, symptom status, and age predicted the total MLHFQ (P < .0001) and the emotional scale (P < .0001), and health perception, symptom status, New York Heart Association predicted the physical scale (P < .0001). Health perception was a mediator of the effect of symptom status on HRQOL. Functional status was not a mediator of the effect of symptom status on health perception.

CONCLUSION

The most influential variables associated with HRQOL were the subjective variables: health perception and symptom status. Objective variables proposed by WCM to drive the model were not significant predictors. Mediator effects hypothesized in the WCM were not fully demonstrated in this sample. Thus modification of the WCM is warranted.

Congestive heart failure patients' perceptions of quality of life: the integration of physical and psychosocial factors

Congestive heart failure (CHF) lowers survival and worsens the quality of life (QOL) of over four million older Americans. Both clinicians and standardized instruments used to assess the QOL of patients with CHF focus primarily on physical symptoms rather than capturing the full range of psychosocial concerns. The purpose of this study was to gather descriptions of the components of QOL as understood by patients living with CHF. Focus groups were conducted with patients with known CHF, New York Heart Association (NYHA) class I-IV, and left ventricular fraction of <40%. Focus groups were audiotaped, transcribed, and reviewed for common and recurrent themes using the methods of constant comparisons. We conducted three focus groups (n = 15) stratified by NYHA stage with male patients ranging in age from 47-82 years of age. Five patients were classified with NYHA stage III/IV and ten with NYHA stage I/II. Thirty attributes of QOL were identified which fell into five broad domains: symptoms, role loss, affective response, coping, and social support. Expectedly, patients reported the importance of physical symptoms; however, participants also identified concern for family, the uncertainty of prognosis, and cognitive function as dimensions of QOL. Changes in patients' lives attributed to CHF were not always considered deficiencies; rather, methods of coping with CHF were identified as important attributes representing possible opportunities for personal growth. Clinicians must understand the full range of concerns affecting the QOL of their older patients with CHF. The findings suggest that psychosocial aspects and patient uncertainty about their prognosis are important components of QOL among CHF patients.

Psychosocial factors and their association with clinical outcomes in patients with heart failure: why clinicians do not seem to care

Poor quality of life, social isolation, depression and anxiety all have been linked to increased risk of rehospitalization and mortality in patients with heart failure. Yet, despite evidence of their importance to outcomes in heart failure patients, psychosocial factors are assessed and treated infrequently in clinical practice. Potential reasons for this include: (1) inadequate dissemination of research about the link between psychosocial factors and outcomes; (2) insufficient training in heart-mind interactions that precludes clinicians from taking advantage of what is known; (3) perceived problems with interventions or with the science of heart-mind interactions that interfere with acceptance of what is known; (4) concerns about how to measure psychosocial factors in clinical practice; and (5) lack of curiosity from clinicians about the role of psychosocial factors in their patients. In this article, each of these possible explanations is explored and recommendations suggested.

Transitions in Health Status in Older Patients with Heart Failure

BACKGROUND

We aimed to determine transitions in health perception and functional status in older Medicare patients with heart failure.

METHODS

We used 1991 to 1994 data from the Medicare Current Beneficiary Survey, a database that combines Medicare claims with yearly longitudinal surveys. We identified 872 patients 65 years or older in 1991 with a diagnostic code of heart failure.

RESULTS

At baseline, 58% of the patients rated their general health perception as "fair" or "poor." Over 1 year, 18% of the patients died. Transition matrices revealed that health perception, activities of daily living, and instrumental activities of daily living were strong correlates of mortality; that dramatic changes in health status were relatively uncommon over 1 year among survivors; and that decline was common in patients with "excellent" or "very good" health perception. The prior year's health status and comorbidity were powerful predictors of the subsequent year's health status.

CONCLUSION

Many older patients with heart failure have worsening health status over time. Measures of prior health status can help predict chances of functional recovery.

The utility of multidimensional assessments of physical health in patient care

Practitioners rely on a variety of measures of a patient's physical condition, including physiologic and clinician assessments. Occasionally, patient self-report data are collected. What insight into the physical health and functioning of patients does each of these types of information yield? This study suggests that each type of information provides a somewhat different insight into a patient's physical condition and that a combination of physiologic, clinician, and patient self-assessments can provide a more thorough assessment of a patient's condition. Using data from a clinical study of patients with heart failure, the Studies of Left Ventricular Dysfunction (SOLVD), measures of these three types of physical health assessments are compared as predictors of hospitalization. Results indicate that the self-report measures performed as well as or better than the physiologic or clinician assessments as predictors of hospitalization. The self-report measures have the added advantage of being inexpensive, noninvasive, and easily obtained over time, allowing for assessments of change. These findings suggest that, while related, each type of measure captures a different aspect of patient physical health and functioning.

Living with heart failure: depression and quality of life in patients and spouses

BACKGROUND

Although spouses are a key support for patients with heart failure, and help them remain in the community, no one has studied patient-spouse pairs to determine the nature of their experience. Therefore, we conducted a study of patients and spouses to compare their levels of depression and health-related quality of life (HRQOL), and to identify factors that contribute to depression and HRQOL in patient-spouse pairs.

METHODS

Forty-eight couples, in which all patients were men with heart failure, were recruited from a university-affiliated, outpatient heart failure clinic. Data were collected using the Beck Depression Inventory, the 12-item Short Form (that measures physical and mental components of QOL), and the 6-minute walk test.

RESULTS

Patients with heart failure were significantly more depressed and had poorer physical quality of life compared with spouses. Patients' depression was correlated with their own functional status and mental quality of life, with the combination of 6-minute walk distance and mental QOL contributing 51% of the variance in patient depression. Spouse depression and HRQOL did not significantly influence patient depression. In contrast, spouses' depression was related to their husbands' functional status and employment, as well as their own mental QOL. The mental component of spouse QOL and the age of the patient accounted for 33% of the adjusted variance in spousal depression.

CONCLUSIONS

Patients with heart failure and their spouses experience significantly different levels of depression and physical QOL. In developing interventions, it may be important to take these differences into account and focus on their unique needs as well as those issues that affect the couple together. Interventions that improve patient functional status may result in decreased depression and improved HRQOL on the part of both patients and spouses.